Health in London – Evidence Paper

1 Introduction

1.1 This paper provides a summary of key evidence gathered to help frame a discussion at the first meeting of the London Health Board, through which the Board will identify the priority issues on which it intends to focus in its first year.

1.2 Given the wide-ranging remit of the Board, this paper covers evidence on health outcomes for Londoners, health & care services and the health economy.

1.3 Once the London Health Board has identified its priorities, further work will be undertaken to ensure a clear understanding of the wider evidence base on these, to inform the Board’s consideration of the actions needed to deliver real improvements to Londoners.

2 The London context

2.1 London is a World City, with a wealth of economic, social and cultural lifestyle opportunities and benefits. The population of London is now over 8.2 million, and is expected to continue to grow to more than 9.5 million over the next 20 years.

2.2 London’s population is young compared with the rest of the country. The average age of a Londoner is 37 compared with 40 for the UK as a whole.

2.3 Ours is a mobile population, with a relatively high population ‘churn’ compared to the rest of the country, as well as internationally. For example, there is a 20-40 percent turnover in each year in GP patient lists; and leaving rates in inner London secondary school are 2-3 times higher in than other metropolitan local authority areas. Londoners also move across boroughs for work, education and leisure.

2.4 London is a hugely diverse city. Around 40 percent of Londoners are drawn from over 90 different minority ethnic groups, speaking more than 300 languages. London is home to some of the wealthiest and some of the most deprived people in Britain. People in the top ten per cent of households earn around five and half times more than those in the bottom ten percent. The gap between rich and poor is increasing.

2.5 London therefore faces a unique set of complex challenges to protecting and improving the health and wellbeing of its citizens.

3 Health of Londoners

3.1 Overall, London’s morbidity and mortality rates are comparable to the English average with better life expectancy compared to seven other large English cities (Capital Concerns. Comparing London’s health challenges with England’s largest cities. London Health Observatory, 2012). This picture, however, masks marked health inequalities across the boroughs. For example, there is a difference in life expectancy for men of nine years between Kensington & Chelsea and Islington.

3.2 As is the case nationally, cardiovascular disease, cancers and respiratory diseases are London’s leading causes of death. Although better than some other parts of the country (Capital Health Gains? London Health Observatory), cancer outcomes remain poor by international standards, largely due to later detection rates.

The main risk factors underlying the three 'big killers' are:

- high blood pressure
- smoking
- excess alcohol consumption
- obesity
- poor diet
- lack of physical exercise.

3.3 A greater proportion of the capital’s population are exposed to health risk factors than other parts of the UK, with significant inequalities across boroughs (see Appendix 1). Of particular concern are levels of childhood obesity, sexual health, smoking and alcohol consumption.

3.4 Mental health is a further area where the capital fares poorly. A greater percentage of Londoners report feelings of low life satisfaction, and feelings of anxiety. Admissions to hospital for mental illness are higher than elsewhere in England, as are diagnoses for depressive disorders. A person with a severe and enduring mental health problem has a life expectancy up to 25 years less than the national average.

3.5 Particular disadvantaged groups also feature prominently in terms of their ill-health. There is clear evidence to show that early years are a crucial stage in child development and have a lifelong bearing on health (The Marmot In terms of health inequalities, looked after children and children in poverty fair particularly poorly.

- Around 60 per cent of looked after children have emotional and mental health problems and are more likely to become teenage parents

- 67 per cent of 'Troubled families' have health issues,

  - 39 per cent have mental health issues
  - 40 per cent have poor physical health (due to lack of exercise / poor diet)
  - 33 per cent misuse drugs
  - 28 per cent have drinking problem

- People in prison are more likely to have or develop health issues that may continue to persist on discharge, e.g.:

  - 70 per cent have two or more mental health disorders (compared to 2-5 per cent in general population)
  - 80 per cent smoke
  - 46 per cent have a long-standing illness or disability (compared to 29 per cent of the general population)
  - 50 times higher Tuberculosis rate
  - 30 times higher Hepatitis B rate
  - 80 times higher Hepatitis C rate
  - 15 times higher HIV rate

- People with learning difficulties on average die 25 years early than the general population and with respect to children with learning difficulties their carers report that they have higher rates of ill-health.

4 Recent trends

4.1 Tremendous strides have been made in recent years to address many health challenges in London such as improvements in childhood immunisation rates and reductions in infant mortality rates and teenage conceptions. (Capital Gains. London Health Observatory, 2012).

4.2 UK analysis of the Global Burden of Disease Study 2010 (UK Health Performance: findings of the Global Burden of Disease Study 2010, The Lancet v381, 2013) however, has shown that while the overall health of the population has improved substantially in absolute terms, the UK continues to perform significantly worse than many of our European neighbours. 5 **Comparisons with other World Cities**

5.1 London is fifth among cities internationally in terms of gross domestic product (GDP). It shares many of the same characteristics of other World Cities as a centre of media, finance, and other specialised services, such as medical research and specialised health care. Like other World Cities, London exerts a powerful influence, not only nationally, but on the rest of the world.

5.2 When the Board considers how it wants to work and agrees the health priorities it wishes to focus on, it will need to look internationally as well as within the UK for ideas and comparisons.

5.3 There are particular cities with which London can compare itself, chief amongst which are New York, Paris, Tokyo and Hong Kong.

5.4 New York, in particular, is a source of information on what can be achieved. The average life expectancy for men increased by 13.6 years between 1989 and 2009, the biggest improvement in the US, showing what a sustained, coordinated public health strategy can deliver.

5.5 *Take Care New York*, taken forward by Mayor Bloomberg, has been particularly effective in terms of what it has achieved and how to develop and implement a coordinated health strategy.

6 **The Health and Care Economy in London**

6.1 London encompasses one of the biggest health regions in England, both in spend and number of people served. (The NHS in London has an annual budget of £15.1 billion for 2013/14). It is also the most diverse. These factors combine to present some unique challenges to providing health services.

6.2 London’s 32 Clinical Commissioning Groups (CCGs) will drive the new system of NHS commissioning and will bring patient benefits through their clinical experience and local knowledge.

6.3 NHS England is responsible for commissioning a range of other health services including primary care, specialised services, offender and military health services, screening services, immunisation and early years’ services, including health visiting.

6.4 The 33 local authorities in London are responsible for children’s and adult social care commissioning (budgets for LA children’s and adult social care in London for 2012/13 were £1.3bn & £3.7bn respectively) and, since 1 April 2013, for many aspects of public health (budgets for LA’s public health functions in London for 2013/14 total £553 million). 6.5 Public Health England (PHE) is the new national body responsible for providing leadership to the public health system; supporting local government by providing evidence and expert advice; and delivering nationwide programmes to support healthy lifestyles. The London regional office of PHE works closely with borough public health teams and pan-London partners to ensure that this leadership and support is tailored to Londoners’ needs.

6.6 The Mayor of London is responsible for developing a London-wide Health Inequalities Strategy and has a number of functions that are important determinants of the health and wellbeing of Londoners, such as transport.

6.7 London has three of the 15 academic health science centres (AHSCs) in England, three Academic Health Sciences Networks (AHSN) and seven of the UK’s 11 biomedical research centres. The research and development sector and associated industries are important drivers to the London economy.

7 Life sciences sector in London

7.1 In 2010 there were 7,055 life science companies in the UK, 995 of whom were in London (14% of the national total). The majority of these companies were in the pharmaceutical sector and a large number were involved in the manufacture of medical and dental instruments. (Source: www.londonmedicine.com, P. Wetherill (2010) UK Business: Activity, Size and Location – 2010. ©Crown Copyright 2010 Office for National Statistics)

7.2 10,400 people were employed in London’s life science industry in 2009 (7% of the UK’s life science employees). The sector tends to comprise small and medium-sized enterprises. In 2008, 73% of London’s life science companies employed 1-4 people, 86% employed 10 people or fewer. (Source: www.londonmedicine.com, adapted from data from the Office for National Statistics licensed under the Open Government Licence v.1.0).

7.3 With the concentration of medical, dental and pharmacy higher education in London, and the close links between the life science industry and academia, it is not surprising that London has a high number of life science companies start up. Between 2005 and 2009, there were 37 life science start-ups in London. (source: www.londonmedicine.com, from UK Life Science Start-up Report 2010 by Glen Crocker, BioCity Nottingham) 8 Healthcare provision in London

8.1 The average catchment population of London’s acute hospitals is smaller than many other regions in the country; as a consequence, activity rates in some sites are comparatively low (except in the case of A&E attendances and maternity services for most sites in London). This has caused some Trusts to experience clinical sustainability challenges, particularly because of medical staffing.

8.2 These relatively low activity rates mean some Trusts face major financial challenges in meeting their high fixed costs. Given the large number of providers in the capital, many areas in London are considering reconfiguring acute services to offer high quality care in more efficient and accessible manners.

8.3 London continues to perform at or above national benchmarks for majority of outcome and improvement indicators for health services.

- London met the 95 percent threshold of patients being seen and treated, admitted or discharged within four hours at A&E across each of the first three quarters of 2012/13, although more recently the NHS is experiencing greater challenges in this area.

- London continues to meet national cancer treatment standards for the 55,000 patients receiving treatment for cancer each year.

- Considerable work has been undertaken to reduce mixed sex accommodation

- Healthcare associated infection (HCAI) rates were reduced in London during 2012/13, with cases of Clostridium difficile (C.diff) in hospitals dropping for the year to date to January 2013.

- Primary care will need to meet a growing range and complexity of health needs. Demographic changes, along with the tighter financial context, pose risks to the quality of care. Changes are needed to the organisation and delivery of primary care to meet these challenges. CCGs will need to work with a wide range of health and social care professionals and with local authorities to help commission and deliver more integrated care for patients with complex health and social care needs.

8.4 Key improvement activities being taken forward include:

- NHS England supporting London-wide primary care transformation. A review of pan-London primary care provision has taken place and strategic commissioning priorities have been identified.

- The NHS 111 service is being rolled out across London through 11 pilot sites, run by four suppliers supported by NHS England.

- The London Cancer Programme is establishing mechanisms for improving the consistency of care for cancer patients.

- Myhealthlondon interactive website which aims to improve information transparency and help increase patient choice.

- Support to coalitions of health and social care leaders to develop integrated care systems serving large populations within London. This work is aimed at providing seamless care to patients through a programme of shared learning and problem solving.

- London supporting Improved Access to Psychological Therapies (IAPT) services. This translates to approximately 60 per cent geographical coverage across the capital. 500 new therapists have also been recruited in London.

- Implementing the Dementia Strategy, including supporting the redesign of hospital and community pathways.

- Work by NHE England and CCGs to develop the commissioning of mental health to improve the services provided to people with longstanding mental health problems, primary care mental health and public health elements of mental health, including prevention and better physical health for people with mental health problems. 9 Local priorities

9.1 The new public health and health service commissioning systems are based on ensuring that the services provided meet local needs and draw on the strengths of those organisations closest to local populations. The work of the London Health Board will need to build on this strength and not cut across it. Working with the grain and not adding to local priorities will be important.

9.2 A review of the work of local Health and Well-being Partnerships in London has identified that many share the same priorities. The top five priority areas are:

i. improving mental wellbeing of adults and children (50% of partnerships)

ii. Reducing obesity rates among children and adults (40%)

iii. Work focussed on long-term conditions (23%)

iv. Integration of health and care services (23%)

v. Early intervention (23%).

9.3 Other priority areas include work tackling alcohol related issues, tobacco control and reducing smoking, improving dementia care, cancer prevention and better service outcomes, reducing cardiovascular disease and increasing physical activity levels. Key healthy outcomes challenges in London

Key health challenges for London include the following, which are not ranked but listed in alphabetic order.

a. Alcohol

Unsafe drinking increases the risk of developing a range of conditions and is the third biggest lifestyle risk factor after smoking and obesity. It is a significant cause of crime, anti-social behaviour and violence. In London, nearly one in five men and one in ten women drink unsafe amounts. There was a 35% increase in under 35s dying from alcoholic liver disease between 2004 and 2008. An estimated 2.4 million Londoners drink alcohol at harmful and hazardous levels. In 2009/10, 93,244 recorded crimes in London were attributable to alcohol. Of these, 64,802 were violent crimes and almost 2,000 were sexual crimes.

Table 1: Binge drinking: percentage of males and females consuming more than 8/6 units of alcohol on at least one day in the last week, 2010

| | Males | Females | |----------|-------|---------| | London | 18.6% | 11.2% | | England | 18.8% | 12.5% |

Figure 1: Early death rate from preventable liver disease, 2009-11

Source: Public Health Outcomes Framework b. Cancer

Despite recent improvements in survival and mortality, cancer outcomes in England remain poor when compared with many other Western countries. Cancer incidence in London and nationally is increasing. Overall mortality from cancer is improving due to a fall in the number of cancers with poor outcomes (such as lung cancer) and improvements in diagnosis and treatment. Incidence and mortality rates for some London boroughs are significantly higher than the national average.

Nationally, survival rates for cancers of the colon, breast, cervix, prostate and bladder are reasonably good: one-year survival is above 65% and five-year survival is above 45%. For cancers of the oesophagus, stomach and lung, however, survival is very low: one-year survival is below 40% and five-year survival is below 20%. Compared with other Western counties, these rates are low.

Figure 2: Cancer incidence for England, London and London borough, 1993-2010

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c. Healthy eating

Poor diet is a risk factor for a number of long term conditions, including leading causes of early death and morbidity such as cardiovascular disease, stroke, diabetes and some cancers. Poor diet can also lead to overweight and obesity – discussed below.

Those with lower incomes are more likely to eat a poorer diet as highlighted by the Health Survey for England, and the Low Income Diet and Nutrition Survey.

d. Illicit drug use

Drug Misuse damages physical and mental health. Problems include; Lung damage (smoking drugs and tobacco raises the risk); liver damage (undiagnosed or untreated Hepatitis C can cause cirrhosis, liver failure, liver cancer and death); poor vein health (many injectors develop circulatory problems and deep vein thrombosis); depression, anxiety, psychosis and personality disorder (70% in drug treatment and 86% in alcohol treatment have mental health problems); cardiovascular disease (a lifetime of drugs, alcohol and smoking raises risk for older drug users); muscles and skeleton (arthritis and immobility are common among injectors).

There are estimated to be approximately 52,000 opiate and crack users in London. The National Drug Treatment System (NDTMS) highlights that a good proportion of these are in treatment. The frozen dataset for 11/12 indicates 31,969 drug users were in treatment in London.

e. Mental health, including dementia, anxiety and depression

London has relatively high rates of severe mental health problems (schizophrenia, bipolar disorder and other psychoses). Evidence shows that even if the most effective treatments were available universally that would only reduce the burden on services by an estimated 28%. Average life expectancy of someone with a serious mental health problem is currently 15-25 year less than for the general population.

Table 2 Self-reported wellbeing scores, 2011/12

| Percentage of people with… | London | England | |---------------------------|--------|---------| | Low satisfaction score | 27.2% | 24.3% | | Low worthwhile score | 22.7% | 20.1% | | Low happiness score | 30.7% | 29% | | High anxiety score | 44.6% | 40.1% |

Source: Office for National Statistics. Annual Population Survey, 2011/12. f. Obesity and overweight

Both obesity and overweight are associated with increased risk of heart disease and stroke, type 2 diabetes, certain cancers and osteoarthritis. The percentage of London children who are overweight or obese is significantly worse than the England average. Within London, there is approximate twofold difference between the boroughs with the highest and lowest rates.

Table 3: Percentage of children who are overweight or obese, 2011/12

| | Reception (ages 4-5) | Year 6 (ages 10-11) | |----------------|----------------------|----------------------| | | Overweight or obese | Number | Overweight or obese | Number | | London | 23.3% | 20,900 | 37.5% | 27,300 | | England | 22.6% | 127,600 | 33.9% | 166,500 | g. Physical activity

An active lifestyle can reduce the risk of conditions such as coronary heart disease, stroke, type 2 diabetes, obesity, mental health problems and musculoskeletal conditions.

- The latest active people survey data for London (December 2012) show 36.5% of people over 16 are classed as active. This is an increase on the 2005 figure of 35%.

- Reviews have highlighted that that lifestyle changes are clustered by socioeconomic status, with the most deprived gaining least benefit from standard interventions. This trend is mirrored in the patterns of inactivity in London.

h. Sexual health

Poor sexual health is responsible for significant levels of ill-health, while teenage pregnancy can result in poor child and maternal health outcomes. London has some of the worst sexual health in the country. The rate of acute STIs in London is over 50% higher than any other region and the 10 local authorities with the highest rates of acute STIs are all in London (ref. HPA London, STI epidemiology in London). The prevalence of diagnosed HIV in adults is over 3 times the rate of any other region in England and 18 of the 20 local authorities with the highest diagnosed HIV prevalence are in London (ref. HPA London). i. Tobacco use

Smoking is the single greatest cause of preventable illness and early death from lung and other cancers, heart disease, stroke, chronic respiratory disease and other conditions, and a major contributor to health inequalities. Over 1.1m Londoners are smokers and smoking is responsible for 8,500 deaths a year in London. An estimated 19% of adults aged 18 and over in London were smokers in 2011/12, slightly lower than the England average of 20%. However, there was wide variation in the estimated proportion of smokers in each London borough, ranging from 14.6% in Harrow to 25.2% in Hackney. 90% of lung cancer is caused by smoking and there are around 3,600 new lung cancer registrations each year in the capital.

About 11% of cigarette sales are from illicit tobacco. The main target market for illegal tobacco trade is young people, routine and manual workers, those on low incomes and the unwaged – therefore having significant implications for health inequalities. Illicit tobacco sales, at lower price, sometimes provided by organised criminal activities, are a factor in promoting use in deprived communities. Studies have shown this to be a significant issue in maintaining smoking rates.

j. Tuberculosis

London has among the highest rates of tuberculosis in England and an increasing proportion of cases are found among people born outside the UK. London accounts for over 40% of new tuberculosis cases in England and the new case rate in some boroughs is over six times higher than the national average.

Table 4: New cases and deaths from tuberculosis

| | New cases (2010) | Deaths (2008-10) | |----------|------------------|------------------| | | Rate per 100,000 | Number | Rate per 100,000 | Number | | London | 40.55 | 3,373 | 0.78 | 196 | | England | 15.35 | 8,168 | 0.41 | 889 |

Source: Compendium of Population Health Indicators.

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i ASH, Cost of Local Tobacco Control, 2012 update [www.ash.org.uk](http://www.ash.org.uk)

ii Public Health England Local Tobacco Control Profiles for England

iii [http://www.tobaccoprofiles.info/](http://www.tobaccoprofiles.info/)

iv Public Health England Local Tobacco Profiles for England

v NEMS Market Research LHIB Illicit Tobacco Research Study, summary, 2012